| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $12 | $20 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $34 | $49 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $12 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $17 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $16 | $24 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $22 | $33 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $197 | $500 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $101 | $283 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $211 | $542 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $101 | $212 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $219 | $564 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $196 | $496 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $172 | $425 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $243 | $850 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $250 | $659 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $269 | $714 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $235 | $612 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $208 | $531 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $213 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $2,874 | $2,874 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $1,742 | $2,241 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $413 | $4,180 | $10,308 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $620 | $2,708 | $5,369 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,989 | $5,989 | $5,989 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $514 | $896 | $1,277 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $803 | $1,390 | $1,978 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $31 | $40 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $17 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $16 | $20 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $131 | $166 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $82 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $289 | $289 | $289 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $356 | $535 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $311 | $426 | $541 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $318 | $483 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $235 | $311 |
| Stress echocardiography CPT 93350 • Cardiology | $156 | $213 | $271 |
| Left and right heart catheterization CPT 93452 • Cardiology | $841 | $873 | $905 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $1,072 | $1,771 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $1,388 | $2,580 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $70 | $117 | $186 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $30 | $71 | $113 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $330 | $411 | $491 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $33 | $154 | $367 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $75 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $63 | $63 | $63 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $134 | $198 | $263 |